The AHA/ACC task force criteria: what is its value in the device era? American Heart Association/American College of Cardiology

Evaluation of the American College of Cardiology/American Heart Association and the Society for Coronary Angiography and Interventions lesion classification system in the current "stent era" of coronary interventions (from the ACC-National Cardiovascular Data Registry)

In 1988 American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for Coronary Angioplasty proposed a lesion classification system to stratify lesions by difficulty and risk to better understand the outcomes of coronary interventions. It was a 3-level (A, B, and C) classification based on 11 lesion characteristics. A modification, dividing the intermediate B category into B1 and B2, is also in common use. Recently, a simplification of this classification was evaluated using the large Society for Cardiac Angiography and Interventions (SCAI) Registry (SCAI I = non-C/patent; SCAI II = C/patent; SCAI III = non-C/occluded; SCAI IV = C/occluded). The lesion classification systems were evaluated in 61,926 patients from the ACC National Cardiovascular Data Registry who underwent single-vessel percutaneous coronary intervention between January 1998 and September 2000. Stents were placed in 74.5% of patients. Logistic models for lesion success and complications were constructed and compared. The c statistic for success using the ACC/AHA original classification system was 0.69, 0.71 for the modified ACC/AHA system, and 0.75 for the SCAI classification. The range of complication and success rates was greater using the SCAI models, and the logistic models for success and complication were more robust for the SCAI system. Thus, in the large ACC-National Cardiovascular Data Registry, with a high percentage of stent usage, the simpler SCAI lesion classification provided better discrimination for success and complications than the more complex ACC/AHA lesion classification system-original or modified.

Frequency of abrupt vessel closure and side branch occlusion after percutaneous coronary intervention in a 6.5-year period (1994 to 2000) at a single medical center

The aims of this study were to analyze the contemporary trends in the changing incidence of abrupt vessel closure (AVC) after percutaneous coronary intervention (PCI), to determine the impact of intracoronary stenting and glycoprotein IIb/IIIa inhibitors (GPIs) on complication rates and etiologies, and to determine the incidence of side branch occlusion (SBO) as the etiology of AVC in the stent era, complications occurring during 3,300 consecutive PCIs performed from April 1994 to December 2000 at a single referral institution. In this consecutive patient cohort of PCI cases collected over a 6.5-year period, AVC occurred in 103 of 3,300 cases (3.12%). Linear regression analysis over this time frame documented a steadily decreasing incidence of AVC from 5.9% in 1994 to 1.1% in 2000 (-0.76%/per year, 95% confidence interval -0.99 to 0.52, p <0.05). Analysis using Pearson's correlation showed that the decreasing incidence of AVC was inversely correlated with the increasing percentage of intracoronary stents placed over this time period (r = -0.94, p <0.001). Additionally, GPI use increased from 0% in 1995 to 36.0% in 2000 (p = 0.009). The absolute incidence of SBO of a major branch vessel remained relatively stable over this 6.5-year period. However, SBO appeared to be increasing as the etiology of AVC, and accounted for 9.0% of AVC in 1995 compared with 28.0% of AVC in 2000. This increasing trend of the percentage of SBO as the etiology of AVC appeared to correlate with the increased use of stents (r = 0.85, p = 0.015). Thus, the incidence of AVC steadily decreased over the 6.5-year time period, and was associated with the increased use of stents and GPIs; conversely, SBO accounted for an increasing percentage of AVC over this time period.

Evaluation of the Society for Coronary Angiography and Interventions' lesion classification system in 14,133 patients with percutaneous coronary interventions in the current stent era

We recently showed that the ACC/AHA coronary lesion classification could be simplified with no loss of predictive value (SCAI I = patent/non-C; SCAI II = patent/C; SCAI III = occluded/non-C; SCAI IV = occluded/C). We now test this system in a database reflecting current stent usage. Data from 14,133 patients with single-native-vessel interventions recorded in the Society for Coronary Angiography and Interventions (SCAI) Registry from July 1996 to July 1999 were analyzed. Stents were used in 60.2% of procedures. Logistic models predicting angiographic success suggested a slight, clinically insignificant preference for the SCAI classification (c-statistic = 0.692 vs. 0.670). Models using clinical variables to predict major complications were superior to models using only lesion classification. Lesion characteristics were related to outcomes primarily in elective (not acute myocardial infarction) patients. In the current PCI device era, the simpler SCAI classification using 7 variables predicted interventional success and complications as well as or better than the ACC/AHA system requiring 26.

A simplified lesion classification for predicting success and complications of coronary angioplasty. Registry Committee of the Society for Cardiac Angiography and Intervention

In 1988, the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures presented a classification of coronary lesions utilizing 26 lesion features to predict the success and complications of balloon angioplasty. Using data from the Registry of the Society for Cardiac Angiography and Interventions (SCAI) we evaluated the ability of this classification to predict success and complications. Lesion success, death in hospital, emergency cardiac bypass surgery, and major adverse events were evaluated in 41,071 patients who underwent single-vessel angioplasty from January 1993 to June 1996. Logistic models using the ACC/AHA lesion classification, vessel patency, or both, were compared. A new classification based on the interaction of the ACC/AHA classification plus lesion patency was compared with the existing ACC/AHA classification. Vessel patency, added to the ACC/AHA classification, improved prediction of lesion success (p </=0.0001). Class A and patent B lesions had similar success and complication rates, so a simplified classification (SCAI) using only 7 lesion characteristics could be created. This system (I: non-C patent, II: C patent, III: non-C occluded, and IV: C occluded) improved prediction of lesion success compared with the ACC/AHA classification (Bayesian Information Criterion statistic: ACC/AHA 16539, SCAI 15956; and area under the receiver- operating characteristics curve 0.659, 0.693, respectively). The SCAI classification was preferred for predicting major complications and in-hospital death and was similar to the ACC/AHA classification for predicting emergency bypass surgery.